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QUESTIONS AND ANSWERS
EXAM
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A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (Ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the
following complications related to the ventriculostomy?:
- Headache
- Infection
- Aphasia
- Hypertension (Correct Answer) − ✅ b. Infection
Monitor for infection and use strict asepsis to avoid life−threatening meningitis.
A nurse is providing education to a client who is to undergo an EEG the next day. Which of the following info should the nurse include in the teaching?
- "Do not wash your hair the morning of the procedure."
- "Try and stay awake most of the night prior to the procedure."
- "The procedure will take approximately 15 mins."
- "You will need to lie flat for 4 hours after the procedure." (Correct Answer) − ✅ b. "Try and stay
awake most of the night prior to the procedure."
Tell the client to remain awake to provide cranial stress and increase the possibility of abnormal electrical activity
A nurse is caring for a client who is postprocedural following a lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? SATA.
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- Use the GCS scale to assess the client
- Assist the client into a supine position
- Administer an opioid analgesic
- Encourage the client to increase PO fluid intake
- Instruct the client to perform coughing and deep breathing (Correct Answer) − ✅ B, D
A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?
a Output equal to the instilled irrigate
- Client reports bladder spasms
- Viscous urinary output with clots
- Reports of strong urge to urinate (Correct Answer) − ✅ c. Viscous urinary output with clots
Urine that is bright red with clots is an indication of arterial bleeding.
A nurse is monitoring the ECG of a client who has hypocalcemia. Which of the following findings should the nurse expect?
- Flattened T waves
- Prolonged QT intervals
- Shortened QT intervals
d Widened QRS complexes (Correct Answer) − ✅ b. Prolonged QT intervals Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals, and laryngospasm.
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A nurse is preparing a client who has a brain tumor for a CT scan. Which of the following factors affects the manner in which the nurse will prepare the client for the scan?
- No food or fluids consumed for 4 hours
- Difficulty recalling recent events
- Development of hives while eating shrimp
d.
- Paresthesia in both hands (Correct Answer) − ✅ c. Development of hives while eating shrimp
Shellfish allergy is contraindication of use of contrast media during a CT scan.
A nurse is preparing an in−service program about the stages of acute kidney injury. Which of the following pieces of info should the nurse include about prerenal azotemia?
- Prerenal azotemia begins prior to the onset of symptoms
- Interference with renal perfusion causes renal azotemia
- Prerenal azotemia is irreversible, even in early stages
- Infections and tumors cause prerenal azotemia (Correct Answer) − ✅ b. Interference with renal
perfusion causes prerenal azotemia.Prerenal = interference with renal perfusion, such as from heart failure or hypovolemic shock.
A nurse is teaching a client who has CAD about the difference between angina pectoris and MI. Which of the following should the nurse identify as indications of MI? SATA.
- N/V
- Diaphoresis and dizziness
- Chest and left arm pain that subsides with rest
- Anxiety and feelings of doom
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